Davita Twin Falls Dialysis Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 39430 Based on observation, policy review, and staff interview, it was determined the facility failed to provide a sanitary environment. This resulted in the potential transmission of infection through cross contamination from common surfaces. Findings include: A facility policy titled “INFECTION CONTROL FOR DIALYSIS FACILITIES,” revised October 2020 stated, under the section titled “DISINFECTION.” “Prior to routine disinfection remove all visible blood. For visible blood or gross blood spills, a 1:10 [10%] bleach solution must be utilized. After all visible blood is cleaned with the 1:10 bleach solution, teammates are to use a new disposable towel soaked with 1:10 bleach solution and clean area a second time ... use an appropriate disinfectant such as 1:100 [1%] bleach solution for routine disinfection of environmental surfaces.” This policy was not followed examples included. 1. The following observations were made in the treatment area on 4/09/24 beginning at 10:47 AM: a. The chair at station 23 was observed to have visible blood on the chairside table and the chair arm from patient use. A PCT was observed cleaning the chair. The PCT was observed using 1% bleach solution to clean the chair. The chair was wiped once with 1% bleach solution. Additionally, she was not observed opening the chair arms to clean the sides of the chair. The PCT was interviewed at the time of the observation and asked what the protocol for cleaning blood was and she stated 10% bleach wipe followed by 1% bleach wipe. She stated she did not see blood on the chair. Additionally, when asked why the chair was not opened to clean the sides she stated the chair did not open. Surveyor was able to open the chair in the presence of the PCT and the chair was re-cleaned. b. The chair at station 24 was observed to have visible blood on the chair seat and chair arm from patient use. The PCT was observed to clean the chair. The chair back was wiped on the perimeter but not the center, and the visible blood was not wiped twice. The PCT was interviewed at the time of the observations and confirmed she saw the blood on the chair. She stated the entire chair was cleaned with 10% bleach solution. Observations were reviewed with the PCT and she confirmed the entire chair needed to be wiped. 2. The following observations were made in the treatment area on 4/10/24 beginning at 10:30 AM: The chair at station 21 was observed to have visible blood on the seat and side arm due to the Patient who had just ended treatment was observed to bleed while holding his cannulation sites. A PCT was observed from the time the Patient left the dialysis station to the time the chair was cleaned. The PCT was observed retrieving rags saturated in 1% bleach solution. The PCT than wiped the chair down and began prepping the machine for the next patient. This surveyor asked if the chair was ready for patient use and the PCT stated “yes”. This Surveyor asked what the policy was for cleaning visible blood on the chair. The PCT was able to verbalize using 10% bleach to clean visible blood. When this Surveyor told the PCT she was observed her using 1% bleach she stated. “no, I grabbed 10% bleach and separated the rags.” She confirmed the chair was wiped once. Observations were reviewed with the DCS on 410/24 beginning at 1:50 PM. He confirmed the area with visible blood should be wiped twice with 10% bleach and then the whole chair should be wiped with 1% bleach. The facility failed to ensure the treatment area was sufficiently clean for patient use. 42316”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 42316 Based on observation, policy review, and staff interview, it was determined the facility failed to ensure all staff used proper hand hygiene for patient care for 1 of 2 station disinfections observed on 4/09/24. This resulted in potential cross contamination between common surfaces. Findings included: A facility policy titled, “INFECTION CONTROL FOR DIALYSIS FACILITIES,” revised October 2020 stated, “HAND HYGEINE [sic] ... All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene [sic] a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” This policy was not followed. Examples included: Observations were conducted in the treatment area on 4/09/24 beginning at 10:47 AM. At station 23, The PCT used a single glove draped over her pointer finger to touch the screen on the dialysis machine. She threw away the glove and did not perform hand hygiene. The PCT then went to station 24 and donned another glove over her pointer finger to touch the screen on the dialysis machine. She then threw the glove away, did not perform hand hygiene, and began to chart on the common computer. The observations were reviewed with the PCT immediately after she was observed. The PCT confirmed the improper glove use and hand hygiene. The facility failed to ensure all staff used gloves and hand hygiene properly.”